Location: Colorado Convention Center, Four Seasons Ballroom 1 & 2
Introduction: Kwashiorkor is a common, high-mortality, acute, and neglected disease of malnutrition with uncertain pathophysiology. Most cases go unreported, it has a mortality sometimes exceeding 40%, and the disease kills at least tens of thousands of children each year. The cardinal findings in this pediatric disease are generalized edema, dermatosis, and hepatic steatosis (commonly termed as ‘fatty liver’). It is known that fatty liver is common in kwashiorkor. These liver changes are a sign of metabolic dysfunction. Many other things are unknown about fatty liver in nutritional edema: its severity on presentation; the time course of resolution with therapeutic feeding; how best it may be used for screening and diagnostic purposes; and, why it occurs at all.
Case Description: A 7-month-old Ugandan male presented to Mulago National Referral Hospital with a chief complaint of one week of generalized edema, as well as two days of cough, diarrhea, and vomiting. The patient developed status epilepticus lasting > 5 minutes with generalized tonic–clonic convulsions. Labs were notable for leukocytosis with lymphocytic predominance and elevated liver enzymes (Table). Ultrasound imaging of the liver was notable for a liver parenchyma echogenicity greater than renal parenchyma echogenicity (see Fig. 1), consistent with hepatic steatosis. The patient progressed through the phases of hospitalized malnutrition care per WHO guidelines and ‘graduated’ to outpatient treatment.
Discussion: Severe acute malnutrition (SAM) is a disease category that includes both kwashiorkor (i.e. nutritional edema) and marasmus (wasting with WLZ/WHZ < −3 SD). The diagnosis of kwashiorkor relies on clinical assessment of edema. Current clinical protocols and discharge criteria are based on edema resolution and anthropometric recovery. Edema resolution is reassuring and can be dramatic. Mothers appreciate outward signs of healing, which clinicians can assess by pressing on extremities. However, resolution of edema does not necessarily correlate with complete clinical improvement. There is a need for ancillary clinical parameters, especially in the context of research to improve kwashiorkor care. Hepatic steatosis in kwashiorkor indicates the presence of underlying metabolic dysfunction, marked by impaired energy distribution and metabolism. Hepatic steatosis is the first organ-level disturbance to manifest and the last to disappear in kwashiorkor.
Conclusion: Portable ultrasonography was used to detect hepatic steatosis in a pediatric patient with kwashiorkor. Liver status in child malnutrition care should be considered alongside edema resolution and anthropometric changes, which are the current criteria for rehabilitation. Investigations of novel treatments that target liver dysfunction in kwashiorkor may be aided by the use of handheld ultrasound, which allows for real-time monitoring of fatty liver resolution. The somehow forgotten topic in a nearly orphaned disease is hepatic steatosis, which is literally and figuratively illuminated using ultrasound. Understanding the phenomenon of paradoxical fatty infiltration in a unique syndrome of undernutrition will guide clinical decision-making to improve care for children.
